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 DOI: 10.1177/1359105304044032

2004 9: 497J Health PsycholAntonia C. Lyons and Emer M. E. Forde

Food Allergy in Young Adults: Perceptions and Psychological Effects  

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497

Food Allergy in YoungAdults: Perceptionsand PsychologicalEffects

ANTONIA C. LYONS & EMER M. E.FORDEMassey University, New Zealand & Aston University, UK

A N TO N I A LYO N S, PhD, is a senior lecturer inPsychology at Massey University, where she teachessocial and health psychology. Her research interestsinclude gender and physical health, as well asrepresentations of health and illness in the media.

E M E R F O R D E, PhD, is a lecturer at Aston University.Her research interests include the organization ofsemantic memory, and the cognitive processes andbrain mechanisms involved in everyday actions.

Journal of Health PsychologyCopyright © 2004 SAGE PublicationsLondon, Thousand Oaks and New Delhi,www.sagepublications.comVol 9(4) 497–504DOI: 10.1177/1359105304044032

Abstract

Although food allergy can haveserious health consequences,little is currently known aboutpeople’s perceptions of foodallergy. The present studyexamined the differences inawareness and perceptions offood allergy and anxietybetween young people with andwithout a food allergy.Participants completed aquestionnaire which askedabout their perceptions andknowledge of allergies,perceived health competenceand anxiety. Of the 162participants 24 reported theywere allergic to at least onefood; these people perceivedthat their allergy hadsignificantly less of an impact ontheir lives than others believedit would. Allergy statusinteracted with perceived healthcompetence to affect anxiety.People with an allergy and withhigh health competencereported the greatest anxietylevels. Very few of the sampleknew the meaning of the term‘anaphylaxis’. Findings arediscussed in terms of healtheducation implications andpossibilities.

Keywords

anxiety, food allergy, foodintolerance, perceptions

AC K N OW L E D G E M E N T S. Acknowledgement text.

C O M P E T I N G I N T E R E S T S: None declared.

A D D R E S S. Correspondence should be directed to:D R A N TO N I A LYO N S, School of Psychology, Massey University,Albany Campus, Private Bag 102 904, NSMC, Auckland, NewZealand. [email: a.lyons@massey.ac.nz]

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T H E I N C I D E N C E of food allergy has beenincreasing over the past decades (Sampson,1996; Sampson, Mendelson, & Rosen, 1992),and peanut allergy currently affects approxi-mately 1 per cent of British pre-school children(Tariq, Stevens, & Matthews, 1996). In thegeneral population there is a widespread beliefthat many people are allergic to food (Young,Stoneham, Petruckevitch, Barton, & Rona,1994), although studies have suggested thatpublic estimates of prevalence of food allergy ismuch higher than it actually is (Altman &Chiaramonte, 1996). Surprisingly, very littleresearch has investigated people’s awareness offood allergies or their perceptions towardsothers with a food allergy. Both awareness andperceptions may have consequences for howsufferers of food allergies are treated. As oneallergy sufferer has commented, ‘people under-estimate how difficult life can be if you sufferfrom food allergies, more awareness needs to bemade’ (Henry & Forde, 1999).

We were particularly interested in the percep-tions older teenagers hold about food allergies.This group of young adults are often leavinghome for the first time, and therefore taking fullresponsibility for their food intake. Such a tran-sition has consequences for managing a foodallergy, and the knowledge and perceptions offriends and peers may influence how an allergyis managed. As Heaven (1996) points out, peerinfluence is one of the most important factors indetermining good health practices. Forexample, young adults are likely to be increas-ingly eating meals with friends, either in restau-rants, in other people’s houses or havingtake-away food. The ritual of ‘checking’ (withthe waiter, staff or cook) whether the meal doesnot contain the allergen is extremely important,especially for those who have anaphylactic reac-tions. If a young person feels that friends orpeers do not fully understand the importance oftheir ‘checking ritual’, s/he may be less likely toengage in it. Evidence shows that young peoplewho die from food allergies do so having eatenaway from home (Gowland, 2001). Therefore,the primary aim of this study was to explore howaware young adults are of food allergies, and theperceptions they hold about people with a foodallergy.

People who live with a food allergy must beconstantly vigilant about food they ingest.

Eating out in restaurants has been described asplaying ‘Russian roulette’ for people who haveanaphylactic reactions (President of Anaphy-laxis Society, 2000, personal communication).Further, people with a food allergy see it as‘socially disabling’ (Henry & Forde, 1999). It islikely that young adults with a food allergy aremore aware and hold different perceptionsabout the consequences of living with an allergythan others. They also may perceive their ownhealth differently than others. Having to thinkcontinually about the health consequences ofingesting specific foods may lead people with anallergy to view themselves as less healthy thanpeople without an allergy. People’s assessmentsof their own health status have been linked tomajor health outcomes, including mortality(Idler & Kasl, 1991). Therefore a secondary aimof this study was to explore any differences inboth awareness and perceptions of food allergy,and perceptions of self-rated health, betweenpeople who report having a food allergy, andthose who do not have such an allergy.

Further, despite the increasing media andpublic interest, very little research has investi-gated the possible psychological effects of livingwith a food allergy. One study has examined theeffects on quality of life for child and adultsufferers and their families, and concluded thatthis condition exerts a profound impact on dailylife (Primeau, Kagan, Joseph, Lim, Dufresne,Duffy, Prhcal, & Clarke, 2000). The uncertaintyof knowing whether food eaten away fromhome may stimulate an attack, along with theconstant vigilance concerning ingesting anyfood, may be extremely anxiety provoking.Indeed, people with food allergy have beenfound to report significantly higher levels of traitanxiety than healthy controls (Addolorato,Ancona, Capristo, Graziosetto, Di Rienzo,Maurizi, & Gasbarrini, 1999). Further, in theEssen Epidemiological Anxiety Allergy studypeople with a variety of allergies were found tobe at five times the risk of developing panicdisorder compared to controls (Schmidttraub,Bamler, & Sschafrathrosario, 1995), althoughnot all studies have found a difference in anxietybetween people with and without allergies (e.g.Bell, Jasnowski, Kagan, & King, 1991).

Whether or not living with a food allergyresults in increased levels of anxiety maydepend on individual difference factors, such as

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self-efficacy regarding health and healthoutcomes. Having a sense of competence hasbeen associated with many positive outcomes(Gecas, 1989, cited in Smith, Wallston, & Smith,1995), and self-efficacy has been related to anumber of health behaviours (see O’Leary,1992, for a review). Individuals’ perceptions ofbeing competent to affect their health outcomeshas been related to health status in arthritispatients (Smith et al., 1995) and has also beenfound to interact with health locus of controlbeliefs to affect adherence in renal dialysispatients (Christensen, Wiebe, Benotsch, &Lawton, 1996). We proposed that having anallergy may affect anxiety, but this may beespecially so for those who are not very com-petent about influencing their own healthoutcomes.

In summary, we carried out an exploratorystudy with young adults who were planning toleave home and attend university in the nearfuture. Given the exploratory nature of thisstudy, we did not distinguish between food intol-erance and food allergy. We aimed to: (1)examine young adults’ awareness of foodallergy; (2) examine young adults’ perceptionsof people with a food allergy; (3) comparedifferences in perceptions of food allergy andself-assessed health status between people withand without a self-reported food allergy; and (4)investigate whether people living with a foodallergy would have higher trait anxiety thanothers, and whether this relationship dependedupon perceived health competence.

Method

Participants and procedureParticipants were recruited from two open daysheld at the University of Birmingham in the UK.This opportunistic sample included 162 youngadults, 136 of whom were women (reflecting thehigher proportion of young women attendingthese psychology open days). The participantswere aged between 15–20 years (M = 16.7, SD =0.7). Participants were asked to complete aquestionnaire, which took approximately 15minutes.

Questionnaire measuresFood allergy status Participants were asked toindicate whether they had any food allergies to

peanuts, dairy products, sesame or to specifyany other food they were allergic to. People withan allergy were asked what age their allergy firstdeveloped, what happened the last time thefood was ingested, what was their most seriousreaction to this food, how many times they hadhad a reaction to the food, whether or not thereaction had become more serious each time,and what medication they carried, if any. Partici-pants without an allergy were asked to skip to afurther section in the questionnaire.

Awareness of food allergy All participantswere asked to indicate what the term ‘anaphy-laxis’ means. Further, to explore how awarepeople without a food allergy were about aller-gies, they were asked if they had ever heard ofpeople being allergic to food, and if so, to listwhich foods people are sometimes allergic to.They were also asked if they personally knewanyone with a food allergy, to indicate whichfood this person is allergic to, how serious theirallergy is (on a seven-point Likert scale from‘not at all’ to ‘extremely’), what happens whenthey ingest the food and what medication theycarry (if any).

Perceptions of food allergy To assess percep-tions of living with a food allergy, all participantswere asked to respond to the following eightquestions about food allergy on a seven-pointLikert scale, which ranged from ‘not atall’/‘never’ to ‘extremely’/‘totally’/‘everyday’.(Those with an allergy responded to the sameset of questions, but written for their experiencerather than generally.)

• How often do you think people with foodallergy think about it?

• How much do you think it would affect theirsocial activities?

• How much do you think it would affect theirhappiness?

• How frightening could a food allergy be?• Do people with food allergy feel in control of

their life?• Do people with food allergy feel in control of

their allergy?• How life threatening could a food allergy be?

Self-rated health To assess self-rated health,participants were asked to rate their currenthealth compared to a person in excellent health

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on a seven-point scale from ‘terrible’ to ‘excel-lent’, following Idler and Kasl (1991).

Anxiety The ‘trait’ section of the State-TraitAnxiety Scale was employed to measure anxiety(STAI; Spielberger, 1983). Participants areasked to respond to 20 statements that describehow they ‘generally’ feel on a four-point scale(almost never, sometimes, often and almostalways). The trait section of the STAI has highinternal consistency and test–retest reliability,and some convergent and discriminant validity(Spielberger, 1983).

Health competence The Perceived HealthCompetence Scale was used to measure thedegree to which an individual feels capable ofmanaging her or his health outcomes effectively(Smith et al., 1995). This scale contains eightstatements regarding perceptions of healthcompetence (e.g. ‘I find my efforts to changethings I don’t like about my health are ineffec-tive’) and participants respond on seven-pointLikert scale, ranging from strongly agree tostrongly disagree. This measure has good inter-nal consistency and test–retest reliability, andsome construct validity (Smith et al., 1995).

Results

Food allergy statusAs shown in Table 1, 24 participants (14.8%)reported that they were allergic to at least onefood. Foods causing the allergy ranged fromnuts and dairy foods, to tartrazine, gluten andwheat. The average age that an allergy firstdeveloped was 5 years (SD = 4.8, range 0–16).Reactions ranged from becoming dizzy or light-headed to losing consciousness or nearly dying.Fifteen participants experienced the samereaction each time they ingested the food, whilefor eight participants the reaction became moreserious each time. Four of the participants witha food allergy carried medication for it, whiletwenty did not carry any medication at all.

Awareness of food allergiesOf those without an allergy (N = 138), 1 personhad never heard of people being allergic to food,44 (32.6%) did not know anybody personallywith a food allergy but did know that peoplecould be allergic to food, while 91 (66.4%) knew

somebody with a food allergy (2 missing). Formost of the participants this person was a friend(70%) or a close family member (17%), and themajority of participants listed the food thisperson was allergic to as nuts (25.9%) or dairyproducts (17.9%).

Of the total sample, 118 (72.8%) did notknow what anaphylaxis means; 22 (13.6%)showed a part understanding, while only 3(1.9%) showed a full understanding (19missing). Those with an allergy showed moreunderstanding of this term than those withoutan allergy (Chi-square = 8.47, p < .05), althoughsurprisingly, some participants who had clearlysuffered an anaphylactic shock reaction oningesting the food did not show any under-standing of this term.

Perceptions of food allergy andself-rated healthEight items were developed to assess people’sperceptions of the impact having a food allergyhas on the sufferer. These items were reversecoded as appropriate, and summed to producean overall scale of Perceptions of Food AllergyImpact. This scale had a Cronbach’s alpha of.60, showing some internal consistency;however, inspection of individual items high-lighted that one item did not relate well to theother items (How much do you think an allergywould affect a person’s happiness?). Therefore,this item was deleted. The subsequent scaleconsisted of 7 items, and demonstrated goodinternal consistency (Cronbach’s alpha = .73).Scores ranged between 11 and 46, with a meanresponse of 33.65 (SD = 6.49). Scores on thisscale were normally distributed, with no skew-ness or kurtosis, and no outliers 4 or more stan-dard deviations from the mean.

To examine differences in perceptions of foodallergy impact between young adults with andwithout a food allergy, an independent samplet-test was conducted. People with an allergyrated having an allergy as having significantlyless overall impact on life (M = 25.00, SD = 7.06)than people without an allergy (M = 35.19, SD= 5.01; t (156) = 8.58, p < .001).

An independent samples t-test was alsocarried out to examine whether people with anallergy perceived their own health as poorerthan people without an allergy. Self-ratings ofhealth did not significantly differ across these

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Table 1. Details of participants’ food allergies

What happened last time ate allergen?————————————————–———————————–—————————————————

other (e.g. How many Has reaction lost tiredness, times had got more

Age allergy Foods conscious- breathing stomach dizziness, a reaction serious Medication Sex Age developed allergic to nearly died ness problems problems rash) to food? each time? carried?

Female 17 16 dairy food √ 3 yes yes—not stated

Female 16 0 nuts √ √ √ 6 no noneFemale 16 2 dairy food √ 7 no noneFemale 16 7 gluten √ √ 1 no noneFemale 17 15 mushrooms √ √ many no noneFemale 16 5 peanuts √ √ 6 yes noneFemale 17 0 broad beans √ noneFemale 16 4 dairy food √ √ many yes noneFemale 17 3 dairy food √ many no noneFemale 17 0 fruit √ 3 no noneFemale 20 0 tartrazine √ many no noneFemale 16 0 milk √ many no noneFemale 17 6 parsnips √ √ 5 no noneFemale 16 6 dairy food √ 3 yes noneFemale 17 15 peanuts √ √ 4 no noneFemale 17 11 peppers √ many yes noneFemale 17 5 peanuts √ 4 no antihistamineFemale 17 7 nuts √ 5 yes adrenalinMale 19 6 eggs √ 20 no noneMale 17 3 peanuts √ 2 yes noneFemale 17 0 dairy food, √ √ 10 no none

wheatMale 16 0 nuts √ √ 6 yes adrenalinMale 17 5 peanuts √ 1 noneFemale 17 5 lockets √ √ 3 no none

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two groups (MS = 4.72 and 4.73 respectively, t(159) = .034, NS).

The effects of food allergy onanxietyAnxiety scores in the present sample wereslightly higher than those reported in highschool students in the USA, with a mean of45.51 (SD = 9.35) (compared to 40.17 (10.53) formen and 40.97 (10.63) for women high schoolstudents; Spielberger, 1983). Scores on theanxiety scale were normally distributed with noevidence of skewness, kurtosis or outliers.

Bivariate relationships between anxiety,perceived health competence and age showedthat anxiety had a weak, positive relationshipwith age (r = .17, p < .05), and a weak, negativerelationship with perceived health competence(r = –.33, p < .01). Point-biserial correlationsbetween these variables with sex, and allergystatus, showed that sex was not related to these

measures, while allergy status was weaklyrelated to anxiety (r = .20, p < .05), such thatthose with an allergy reported more anxietythan those without an allergy.

To examine the effect of food allergy andperceived health competence on anxiety, a 2x2ANCOVA was carried out with age included asa covariate. Perceived health competence wasdichotomized at the median. Higher-orderinteractions were included in the model. Resultsshowed only a main effect for allergy (F (1,142)= 6.80, p < .01), such that young adults with anallergy reported higher levels of anxiety thanyoung adults without an allergy (means = 50.55and 44.6, respectively). However, allergy statusinteracted with perceived health competence toaffect anxiety (F (1,142) = 4.10, p < .05). Toexamine the nature of this relationship,subgroup means were calculated and are shownin Fig. 1. Among young adults without anallergy, those who were highly competent about

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35

40

45

50

55

low high

Perceived Health Competence

Anx

iety

Sco

res

no allergy

allergy

Figure 1. Effects of food allergy and health competence on anxiety.

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their health had less anxiety than those whowere not so competent. The reverse pattern wasobserved for young people with an allergy.

Discussion

The primary aim of this study was to investigateyoung people’s awareness and perceptions offood allergy. Almost all of the respondents knewsomething about food allergies and most hadpersonal contact with somebody with an allergy.Almost 15 per cent of the sample reportedhaving a food allergy, although there were morewomen than men in this study, and women havebeen found to report more incidences of foodintolerance than men (Parker, Sussman, &Tarlo, 1990). As allergy status was self-reported,this study does not distinguish between peoplewith food allergy and food intolerance (althoughmany people do make a diagnosis of allergy forthemselves; Lessof, 1995).

Five participants reported allergy symptomsthat were clearly consistent with anaphylacticshock, while 19 participants reported a range ofallergy symptoms. It is concerning that onlythree out of five participants who hadexperienced anaphylactic reactions in the pastcarried antihistamine or epinephrine/adrena-line. Although one participant with a peanutallergy reported that she had had at least sixallergic reactions and had ‘nearly died’ on themost recent occasion, she did not carry anymedication. Similarly, another participant witha peanut allergy had experienced ‘breathingproblems and an itching, swelling mouth’,classic indicators of a serious allergic reaction,but again she had no medication. Clinicalmanagement of this condition depends onpatients having a clear understanding of theimportance of vigilance in food choice and incarrying the appropriate medication in case of asevere reaction. Hourihane suggested:

The appropriate provision of epinephrine1

and education of subjects and their carers inits use in the event of reactions will remain thebenchmark by which the care of peanut aller-gic subjects will be judged for several years tocome. (1997, p. 1245)

Our findings suggest that this benchmark of careis not being reached for all individuals.

All participants except one had heard of

people being allergic to food. However, themajority of the participants, both those with andwithout an allergy, did not know what the term‘anaphylaxis’ means. Somewhat surprisingly,people with an allergy rated their allergy ashaving less of an impact on their lives than theirpeers perceived. This is reassuring as it indicatesthat young adults do take food allergy seriouslyand are aware it has effects on sufferers’ lives.This also highlights that young adults may be anappropriate target for health education, toreinforce the ways in which they can supportand assist people in managing a food allergy. Nodifferences existed between people with andwithout a food allergy in terms of their self-assessments of their own health, showing thatliving with a food allergy does not (at this age)influence self-rated general health.

A further aim of this study was to examinedifferences in anxiety between those with andwithout an allergy. Consistent with previousresearch (Addolorato et al., 1999), people withan allergy had significantly higher levels ofanxiety than those without an allergy. Contraryto expectations, this was particularly so for indi-viduals with an allergy who also felt themselvesto be very competent with regard to their health.This may be because their perceivedcompetence led to increased vigilance, andhence increased anxiety. Constantly dealingwith the hassle of checking food labels may beextremely anxiety provoking for some indi-viduals. Previous research highlights that minordaily stressors have been linked to negativemood, including anxiety, in a healthy adultsample (Bolger, DeLongis, Kessler, & Schilling,1989).

The cross-sectional nature of the studycautions against interpretation of direction ofcausality. People with higher levels of traitanxiety may be more likely to self-diagnose foodallergy than others. Comparing the level ofanxiety in individuals with food allergies testedby double-blind placebo trails would be a usefulextension of this research. In future studies, itwould also be important to compare the levelsof anxiety reported by young people with poten-tially fatal food allergies (e.g. to peanuts orsesame) to those with food intolerance that isnot potentially fatal. Additionally, these findingsare exploratory and the sample very specific,namely a group of intelligent, young adults

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attending an open day at a UK university, socaution must be taken in generalizing theseresults outside of this population.

This study raises a number of important ques-tions, and provides a basis for examiningperceptions of food allergies and possiblepsychological consequences of living with anallergy in future work. Although we chose toexplore the effect of food allergy on the lives ofyoung people applying to university in thepresent study, the psychological effects of foodallergy on individuals of all ages, and the widerimpact on family life, urgently requires investi-gation.

Note

1. Epinephrine (or adrenalin) is the most effectivetreatment for patients who are having an anaphy-lactic reaction. Antihistamine is efficacious formilder (non-anaphylactic) allergic reactions.

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